Shared decision making on mode of delivery following a prior cesarean delivery in Dar es Salaam, Tanzania

Background Shared decision-making between clinicians and pregnant women with prior cesarean on the subsequent mode of delivery improves trial of labor rates, and reduces the number of repeat cesarean sections and their related complications. However, this practice is insufficient worldwide and the factors influencing it are still unknown. The study aimed at determining the proportion of pregnant women involved in shared decision-making and its associated factors in Dar es Salaam. Methods A cross-sectional analytical study among 350 pregnant women with one prior cesarean section. Data was collected using a structured questionnaire and SPSS 23 was used for analysis. A score of 80 or higher on the nine-item Shared Decision-Making Questionnaire (SDM-Q9) was used to calculate the proportion of women, and the associated factors were obtained using a logistic regression model. P value of < 0.05 was considered significant. Results The proportion of pregnant women involved in shared decision making was 38%. Factors that were significantly associated with sharing decision making were; having low level of education (AOR 0.55 95% CI 0.33–0.91), being married/having partner (AOR 2.58 95% CI 1.43–4.63), having a companion who had active participation (AOR 3.31 95% CI 1.03–10.6) and being familiar with the clinician (AOR 5.01 95% CI 1.30–19.2). Conclusion To promote practice of shared decision making in our setting, encouragement of socially vulnerable pregnant women’s participation in decision-making by health care professionals, encouragement of companion participation during antenatal care and promotion of personal continuity of care to improve familiarity to clinicians are needed.


Introduction
Worldwide, the rate of births by Caesarean section (CS) is rising, varying from 5% in Sub-Saharan Africa to 42.8% in Latin America and the Caribbean [1].The rate of CS in public healthcare settings was 15.6% in Ghana and 64.2% in private settings, in Sub-Saharan Africa [2].In Tanzania, the population-based CS rate rose from 2% to 6% over the past two decades   [3].Alarmingly, facility-based studies document a 30-percent point rise in the CS rate in tertiary level centers over three years, from 19 to 49% between 2009 and 2011, with the most prevalent cause being the prior cesarean section [4,5].Additionally, recurrent CS-related morbidity and mortality have been also been increasing [4].
Uterine rupture, placenta previa, placenta accrete spectrum, hysterectomy, intra-abdominal adhesions, and bladder injury are among the morbidities linked to recurrent CS [1].Current practices encourage women with one prior cesarean delivery to attempt vaginal birth with their subsequent pregnancies [6][7][8].It is anticipated that the trial of labor after cesarean (TOLAC) will lower the high rates of cesarean deliveries that have been documented globally and their associated complications [1].However, the national hospital in Tanzania recorded a very low rate of TOLAC in 2007-0.14%[9].
The main causes of the decline in TOLAC are clinicians' fears of TOLAC-related adverse effects and of being held accountable or facing legal action from the medical community [10][11][12][13].Currently, it is advised that the choice of delivery method for eligible pregnant women with a history of CS be made through shared decision-making (SDM), during which the pregnant woman should be informed of the risks and benefits of the two delivery options (TOLAC and repeat CS) [6][7][8].
SDM is recommended so as to support patient autonomy, promote the good clinical practice, and improve patient experiences [14,15].Studies conducted in various contexts found that SDM increased TOLAC rates [16,17], decreased repeat CS by 40%, and improved decision-making and quality of care [16,18].Unfortunately, SDM is not consistently practiced globally [16][17][18][19][20][21][22], and barriers to its use include low women's social economic status and education level as well as clinicians' fear of unfavorable outcomes [10][11][12][13][22][23][24][25][26][27] There is a dearth of knowledge on SDM practices on the delivery method for pregnant women who had one prior CS and the obstacles that lead to fewer SDM practices in the Tanzanian context.The study's findings will provide an understanding of current SDM practices and suggest potential directions for stepping up SDM implementation efforts in our environment.These would potentially increase TOLAC, lower our setting's high rates of repeat CS, and enhance patient care.

Study design, setting and population
A cross-sectional analytical study was conducted from August to December 2020 in the antenatal clinics of Amana, Temeke, and Mwananyamala hospitals.The three hospitals are regional referral hospitals located in Dar es Salaam, which has a population of over 6 million and is the major commercial hub in Tanzania.The hospitals recorded CS rates of 35%, 43%, and 36% in the second half of 2020, respectively.Women with prior CS deliveries in the past are treated at referral hospitals because they are considered to be at high risk.
We included all women with one prior CS scar, a singleton pregnancy in cephalic presentation at �34 week's gestation and who had two or more antenatal care contacts at the study facility.This was considered adequate contact time to have a dialogue on SDM.Women who had contraindications to subsequent vaginal deliveries using local guideline such as prior classical scar, mal presentation and twins were excluded from the study.

Sample size
Using a single population proportion formula at 95% power and an estimated proportion of 30.6% [19] from a nearby country, Kenya, we calculated the sample size to be 350 women with prior CS deliveries.The selection was then taken using probability proportion to size sampling from the three facilities.At each facility participants were recognized with the aid of a checklist, and consecutive sampling was used to recruit the participants as the eligible participants were few.

Study tool
Structured questionnaire in the local language: Swahili was used.The questionnaire was adapted from original German SDM-Q9 [28] and had two parts: part one for participant's demographic and socio-economic; age, education level, employment status, marital status and payment category.Part 2 had 9-item SDM scale (SDM-Q9).The SDM-Q9 questions used Likert scale with 5 points: ranging from 'completely disagree' to 'completely agree' scoring 0 to 5. Participants were instructed to select one option that best matched their perceived involvement in each step of the SDM process during the last six months of ANC contacts.Familiarity was defined by pregnant woman personally knowing her clinician or by being attended by same clinician on a prior visit and graded by Likert scale and companion participation was when the person (husband/relative/friend) accompanying the pregnant woman to the clinic actively took part or asked about the modes of delivery, benefits and harm.The questionnaire was paper-based and interviewer administered, and was pretested among 20 eligible women at a similar high-volume health facility.

Data collection procedure
A pair of research assistants was stationed at antenatal clinics of each of the study facility.Eligible women were identified and recruited at registration.Those who consented were interviewed in a quiet room after completion of clinical care services.

Data analysis
Data was cleaned and checked for completeness and consistency.Variables were coded into SPSS Version 23 where analysis was done.The descriptive variables were categorized as: Education; no formal/primary education and secondary school and above, age; 20-34 years and >35 years.Marital status; married/cohabiting and single/divorced/widowed, Employment status; employed/self-employed and no employment, payment category; health Insurance/private and cost sharing.Participant and companion participation; participated and not participated and familiarity with clinician; familiar (knowing the clinician very well, well, rather well) and not familiar (not well, not well at all).
The variables were summarized using frequencies and percentages.For SDM: The raw score obtained from 9-item SDM scale which had a maximum score of 45 was transformed as suggested by original SDM-Q9 [28] by multiplying the score to 20/9 to get a score of SDM ranging from 0-100 and score of �80 was used to obtain proportion of women with SDM.Measures of association were calculated using cross tabulation and binary logistic regression.The association between the categorized age, education level, marital status, occupation, mode of payment, active participation and familiarity to clinicians as independent variables and SDM as dependent variable was obtained by multivariable logistic regression model at P-value of <0.05.

Ethical issues
The study was reviewed and received ethical permit from MUHAS Ref No MUHAS-REC-06-2020-283.All participants consented.Those who were eligible received information about TOLAC.

Results
During the study period, 1940 pregnant women attended antenatal clinic at the facilities, approximately 24.9% (484/1940) had one prior CS scar.Three hundred and sixty were eligible for recruitment, ten-women did not consent on fear of long waiting time, and 350 women were interviewed.

Demographic and economic characteristics of the study population
Majority of women (93%) with one CS scar were between 20-34 years of age.Mean age was 28.16 ±4.27.Two thirds of the participants were living in union, were employed and had secondary education or above as shown in Table 1.Approximately 58% had private insurance.

Proportion of SDM and factors associated with SDM among pregnant women
The proportion of pregnant women with one prior caesarean who were involved in SDM on their mode of delivery for the index pregnancy at all facilities was found to be 38% (133/350).
As shown in Table 2, women with no education and primary education had less odds to be involved in SDM compared with those with secondary education and above (AOR 0.55, 95% CI (0.33-0.91), with P-value = 0.02).Women who were married/cohabiting and women with companion who had active participation were almost 3 times more likely to be involved (AOR 2.58, (95% CI: 1.43-4.63),p-value 0.001) than women who were single/widowed/ divorced and those who had no companion participation.Participants with familiarity to clinicians had 5 times the odds to be involved in SDM 2.58(95% CI: 1.43-4.63)P-value of 0.02.

Discussion
Nearly a quarter of women who attended antenatal clinics at the referral facilities had one prior CS and lower than half were offered SDM for their index delivery method.Women who reported to have received SDM were more educated, married, or living with a partner, had a companion with active participation in antenatal care, and were familiar with the clinician providing the care.
The study found lower than half of pregnant women with one prior CS was involved in SDM, similar to studies in other various regions [19,20,27,29].On the other hand, SDM was high in a hospital associated with a tertiary university in Peru [30].The study in Peru was done among women with high health literacy, which positively affects SDM.This could account for the difference.
Women with less education had fewer odds of participating in SDM than women with more education.The findings are consistent with other studies that have demonstrated that women with higher levels of education have greater odds of experiencing SDM than women with less education because they are more self-assured and inquisitive [23][24][25][26][27]31]According to a qualitative study in Tanzania, less educated women are also less likely to participate in SDM because healthcare providers believe they won't comprehend things clearly and quickly [22].
Similar to what has been reported in other areas, cost-sharing group women had lower odds of participating in SDM compared to private/insured women, though the relationship was not statistically significant [23,26,32].The study also discovered that employed women were more likely to participate in SDM than women in the unemployed group in line with other studies [31,32].Due to their perceived low social-economic status, the cost-sharing and unemployed groups were less likely to be involved in decision-making.The results, however, differ from studies that found that low-income and unemployed patients received more information during consultations [25,33] Women who started the conversation about their delivery method were more apt to participate in SDM.The results are consistent with observational research that found that clinicians provided patients with more information when they inquired about their treatment [25].The results concur with other reports from various regions [34][35][36][37].According to a qualitative study conducted in Tanzania, doctors were less engaged with patients who were not active in communication [22].
Patients are more likely to feel confident and engaged in discussing their treatment options when they have the support and encouragement of their family.The study found that companion participation in the conversations during antenatal visits had a favorable effect on SDM consistent with other studies [26,38,39].Similarly, a greater degree of SDM was found in the married group compared to the divorced group, indicating the influence of family on the patients' care.These findings further highlight the importance of companion participation in antenatal care.
According to studies in various regions, patients' familiarity with their clinicians has been found to have a substantial association with SDM.[26,32,40].Being comfortable with the clinicians helps with communication, confidence in the clinicians, and the impression of a more well-defined treatment plan.Majority of the pregnant women reported feeling familiar with clinicians after being treated by the same clinician more than twice.This result suggests that by enhancing personal continuity of care in clinics, SDM will be promoted.

Strength of the study
The study used quantitative approach which provides numerical data as a baseline for future comparison as studies in this area are limited in Tanzania.The use of three different regional referral hospital provided diversity among study population which increases the ability to generalize the study results.

Implication to practice
The less involvement of patients in SDM revealed in this study will encourage practitioners to incorporate SDM in daily practice to improve quality of care.The findings will also enlighten them on how to improve the practice of SDM.

Study limitation and mitigations
The study assessed patient's perception of SDM and not actual provider behavior, which may include their self-report and recall bias.This was mitigated by asking patients to recall information they were given for the past six months.

Conclusion
The practice of SDM on mode of delivery among pregnant women with prior caesarean has been found to be low despite promotion of patient centered care in medical practice.Therefore efforts are needed to improve the implementation of SDM.Encouragement of companion involvement during antenatal care, promotion of personal continuity of care which improve familiarity of patients to clinicians and encouragement of clinicians to involve socially vulnerable population are recommended.